Section 125 Premium Only Plan and Medical Expense FSA Order Form

Purchaser Information

Click an input box for help information.

Purchaser Name

The "Purchaser" is the person placing the order, not necessarily the "Employer" listed in the plan document, or the person paying for it. Enter the name of the person that you would like us to contact if we have any questions about the order (i.e. Accountant, Agent, TPA, Payroll Company, or HR Mgr., etc.).

First Name *

Last Name *

Company Name *

Address *

City *

State

Zip Code *

Phone *

Fax

E-Mail *

Employer Information for Plan Documents

Employer Information

NO HYPHENS! Enter the legal name of the Employer, EXACTLY as you would like to see it in your plan document. Do not type all in upper case or all in lower case; check your spelling and punctuation. No hyphens as they issue a STOP command on form. If using a DBA, or the legal name includes a DBA, please include in the Notes the full legal name and which name you would like us to use as the common name in the documents.

Please enter the physical address of the Employer. If you have a P.O. Box or alternate address that you would like the document mailed to, this may be entered in the Notes or on the credit card payment form.

*Auto-Fills Purchaser Information in the Employer Fields Below.

First Name *

Last Name *

Company Name *

Address *

City *

State

Zip Code *

Phone *

Fax

E-Mail *

Business Info

Please Provide your Business Information. Form of business, state of incorporation, and FEIN Required. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.

Form of Business

Employer Federal ID# *

State of Incorporation

Number of Employees *

Legal Name(s) of Affiliated Company(ies)

Please be sure to include the FEIN Number in the notes section below.

Legal Names of Affiliated Companies

If another company is owned by this Employer, and they want to include the other company's employees in this benefit, add it as an Affiliate Company. Please print legal name exactly as you would like it to appear in the document. Include FEIN in the Notes.

Name of Plan Administrator: (Employer unless otherwise stated)

Plan Administrator

The Plan Administrator is typically the Employer. Unless there is a specific entity that you would like designated as Plan Administrator, you may leave the Plan Administrator fields blank.

If the Plan requires submission of Claims, this Fax # will be included on the Claim Form.

*Auto-Fills Purchaser Information in the Plan Admin Fields Below.

*Auto-Fills Employer Information in the Plan Admin Fields Below.

Name

Address

City

State

Zip Code

Phone / Fax

Name of Benefit Programs to be Offered:

Select All Insurance Premiums that are applicable

Reimbursement of (non-employer sponsored) Individual Health Insurance can only be reimbursed post-tax, all other employer sponsored group health plan premiums can be pre-taxed. Group Term Life Insurance can be pre-taxed for the Employee only, and limited to the first $50,000 of face value. Other types of insurance may include Specified Illness, Critical Care, and other eligible health and accident policies.

Other

Health FSA Annual Plan Limit:

The IRS limits Health FSA plans to $3,200 in employee contributions (effective 01/01/2024). Choose the standard $3,200 option, or designate a lower employee contribution limit in the option below.

Annual Plan Limit

New IRS regulations allow one of these two options for spending unused Health FSA benefits. The $640 Carryover Provision limits the amount carried over without time restrictions. The 2.5 month Grace Period provision has no limit on funds but only 2.5 months to spend down unused plan benefits.

Annual Plan Limit

Please Choose One:

$640 Carryover Provision
Employees can carryover up to $640 of unused Health FSA benefits to the next plan year.

2.5 month Grace Period Provision
Employee has 2.5 months after plan year to spend-down unused Health FSA benefits

Effective date will be:

Choose New Plan or Amended Plan

If you have never provided this benefit before, choose New Plan - A and enter first date of pay period when benefit will begin.

If you began giving this benefit to your Employees more than three months ago, chose an Amended Plan - give dates for B and C.

New Plan Document

New Plan (add Effective Date below)

A) Effective Date of New Plan

-OR-

Amended Plan (Effective & Original Dates below)

B) Effective Date of Amended Plan

C) Effective Date of Original Plan

Plan year - The first plan year will be

If you are starting mid-year, your first Plan Year will be a short Plan Year.

Plan Year

In most cases, the Plan Year will be January 1, through December 31. Or the Plan Year can coincide with the Employer Health Plan, however the Employer may choose any twelve month period.

Select Plan Year Type

First Plan Year is 12 consecutive months
(Example: January 1 to December 31)

Plan Year Start Date

Plan Year End Date

-OR-

First Plan Year is a Short Plan Year
(Indicate Start Day and End: Example June 1 to Dec. 31)

Start Date

End Date

Eligibility requirements:

All employees regularly scheduled to work ____ or more hours per week.

Who is Eligible

Minimum = 1 Maximum = 40

Hours per Week: *

Waiting Period:

Employees are eligible the first day of the month coinciding with or next following ____ consecutive days of employment:

Plan Activation

Please enter the number of days of employment before employee eligibility. Minimum = First day of Employment. Typical = First day of month after 30, 60 or 90 consecutive days of employment.

Special Scenario

Number of Days

Other

Wrap SPD

Do you have the Department of Labor and the Affordable Care Act required Wrap SPD for your Group Insurance Plan?

What is a Wrap SPD?

If you offer group health insurance you�re now required by ERISA law, enforced by the Department of Labor and now the Affordable Care Act, to distribute a Wrap SPD within 120 days of the Plan�s effective date. Failure to provide the Wrap SPD within 30 days of request triggers a $110 a day fine per participant. Not having a Wrap SPD can also trigger an audit by the Department of Labor. The insurance company�s Master Contract, Certificate of Coverage, or Summary of Benefits is not a Wrap SPD. This requirement applies to all employer sponsored group health insurance offerings, including a one-person plan. See our Wrap SPD webpage in the blue drop down menu for more information.

We value your feedback

How did you hear about us?

Customer Survey

Please take a moment to provide some feedback on your experience.

Method:

Other:

Choose Your Plan Options (POP & FSA)

Choose one of these three plan document options:

Deluxe Binder - New Core Premium Only & Health FSA Plan Document PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail 249.00

Receive both the printed document and binder AND free PDF email version.

Basic PDF Option - New Core Premium Only & Health FSA Plan Document - PDF email 199.00

PDF Document Processed Quickly and Sent Via E-Mail

Update PDF option - Update an Existing Core Premium Only & Health FSA Plan Document - PDF email 169.00

This option only available to existing Core Documents clients.

Additional Plan Document Options:

HSA Module - pretax HSA savings for additional 7.65% tax savings 30.00

Plan Document. SPD. Administrative Sections & Forms on CD mailed 25.00

Documents provided in PDF format only. Forms in MS Word format

Rush Order - automatically queued up for priority processing 25.00

2nd Year Update - discounted 23% when added to new document order 149.00

This option entitles you to one plan document amendment in the first 24 months. Save 12% off the normal $169.00 update price.

Dependent Care Assistance Plan (FSA) pretax childcare -Save 22% 100.00

Save 25% off normal $129 DCAP FSA price when added to the Premium Only Plan. DCAP employee contributions set at $5000 by the IRS. To limit the DCAP FSA employee contribution please indicate preferred annual limit in the Notes area below. Delivered via email in PDF format unless the binder option is chosen above.

Notes Section

Please utilize the notes section below.

NOTES AREA: Add any special notes regarding a dba name, delivery address (physical and email), eligibility requirements, etc. For HRA plan documents please give us as much detail as possible about exactly how you would like your custom HRA to be designed. A benefit specialist will contact you regarding specific questions, plan design issues, or additional information needed.

Next Step

You can Review your Selection on the Next Page. Use the Back button to return here for corrections. All fields should retain filled content (if you have Cookies activated) except for a couple check boxes. Please check all fields before continuing if returning for corrections.

Click an input box for help information.

Purchaser Name

We normally ship the document to the Purchaser if the binder option is chosen. If this is NOT the address that you would like the plan document shipped to, please indicate the correct shipping address on the credit card payment form and/or in the Notes section at the bottom of this order form.

City where we ship the plan document, if binder option is chosen.

Example: (123)456-7890

Example: (123) 456-7890

We normally email the PDF copy of the plan document to the Purchaser's email. If this is not the email for delivering the plan document please indicate the correct delivery email in the Notes area at the end of this order form.

Employer Information

*Auto-Fills Purchaser Information in the Employer Fields Below.

Normally the business owner or Key Employee. Please enter the first name of the person authorized to sign the plan document.

Normally the business owner or Key Employee. Please enter the last name of the person authorized to sign the plan document.

Please enter the physical address of the Employer.If you have a P.O. Box or alternate address that you would like the document mailed to, this may be entered in the Notes or on the credit card payment form.

#####-####

Example: (123) 456-7890

Example: (123) 456-7890

Indicate in the Notes area below if you would like to have the plan document PDF copied to this email address.

Business Info

Please indicate the form of business.

Required. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.

If not Incorporated, what State laws are you governed by?

Include all W-2 Employees (part-time and full-time), does not need to be exact number. Minimum = 1, No Max

Please be sure to include the FEIN Number in the notes section below.

Legal Names of Affiliated Companies

If another company is owned by this Employer, and they want to include the other company's employees in this benefit, add it as an Affiliate Company. Please print legal name exactly as you would like it to appear in the document. Include FEIN(s) in the Notes.

If you have more than four Affiliated Companies they can be added in the Notes at the end of the order form.

Plan Administrator

*Auto-Fills Purchaser Information in the Plan Admin Fields Below.

*Auto-Fills Employer Information in the Plan Admin Fields Below.

The Plan Administrator is typically the Employer. Unless there is a specific entity that you would like designated as Plan Administrator, you may leave the Plan Administrator fields blank.

Example: (123) 456-7890, If the Plan requires submission of Claims, this Fax # will be included on the Claim Form instead of the Employer's Fax #

Select All Insurance Premiums that are applicable

Add other types of insurance not listed such as Specified Illness, Critical Care, and other eligible health and accident policies. The HSA Pre-Tax Savings Module is a $30 Option Below

The IRS limits Health FSA plans to $3,200 in employee contributions (effective 01/01/2024). Choose the standard $3,200 option, or designate a lower employee contribution limit in the option below.

Annual Plan Limit

We don't normally recommend limiting the allowed $3,200 maximum benefit. The downside to the employee is over-estimating their benefit and the use-it-or-lose-it clause for benefits left over in excess of either the $610 carryover, or 2.5 mo. grace period to spend down unused funds.

Employees can carryover up to $640 of unused Health FSA benefits to the next plan year.

Employee has 2.5 months after plan year to spend-down unused Health FSA benefits

Choose New Plan or Amended Plan

If you are starting mid-year, your first Plan Year will be a short Plan Year.

Plan Year

(Example: January 1 to December 31)

Choose Date on Calendar

Choose Date on Calendar

(Indicate Start Day and End: Example June 1 to Dec. 31)

Choose Date on Calendar.

Choose date on the calendar.

All employees regularly scheduled to work ____ or more hours per week.

Who is Eligible

Employee must be regularly scheduled to work __ or more hours per week. Minimum-1, Typical-32, Maximum-40

Employees are eligible the first day of the month coinciding with or next following ____ consecutive days of employment:

Plan Activation

Employees can participate the first day of the month following this number of days of employment.

If more space is needed, please add your description of eligibility requirements in the Note section at the end of the Order form.

Do you have the Department of Labor and the Affordable Care Act required Wrap SPD for your Group Insurance Plan?

What is a Wrap SPD?

Please see our Wrap SPD webpage for more information.

How did you hear about us?

Customer Survey

How did you hear about us?

Please utilize the notes section below.

You can Review your Selection on the Next Page. Use the Back button to return here for corrections. All fields should retain filled content (if you have Cookies activated) except for a couple check boxes. Please check all fields before continuing if returning for corrections.